I saw the note on the patient's chart before I opened the door: "patient is upset that he had to come in."

I opened the door and was greeted by a gentleman with his arms crossed tightly across his chest and a stern expression.  I barely recognized him, having only seen him a handful of times over the past few years.  Scrawled on the patient history sheet  in the space for the reason for his visits were the words: "Because I was forced to come in."

By stomach churned.  I opened his chart and looked at his problem list, which included high blood pressure and high cholesterol - both treated with medications.  He was last in my office in November...of 2008.  I blinked, looked up at his scowling face, and frowned back.  "You haven't been in the office for over eighteen months.  It was really time for you to come in," I said, trying to remain calm as I spoke.

He sat for a moment, then responded with very little emotion: "I am doing fine.  You could have just called in an order for labs and called in my prescriptions.  I don't know why I had to be seen."

"You have hypertension and high cholesterol.  These are serious medical problems, and if I am going to put my name on a prescription for you, I have to make sure everything is OK," I responded, trying to hide my growing anger.  "I am not a vending machine that you can call to get drugs."

"I'll come in if I am sick, but I am not sick right now."

"My job is to make sure you don't get sick in the first place!" I said, my volume rising slightly.  "I don't bring you in because I need the business; I've got plenty of patients to fill my schedule.  These medications are not risk-free.  Besides, how do I know if your blood pressure is OK?"

"I check my own blood pressure at home and it has been good.  I can't afford to come in to the doctor so much.  I have a high-deductible plan.  I had a stress test and a colonoscopy last year, and that's enough spending for me," he responded, his pitch and volume rising with mine.

"I have to say that I find this personally insulting,"  I threw back.  "You don't think I am worth paying to see.  You just want me to give you your medications, take the risk of adverse reactions, and basically work for free?"

"That's not what I said!"

"It is exactly what you said!" I said, not hiding my frustration.  "You want me to prescribe a medication, trust you for your blood pressure, interpret the lab results, and take the legal risk for your prescriptions and not get paid a dime for it!  You are asking me to give you bad care because you don't think I am worth paying.  I don't do that. I won't give you bad care.  If you wan't bad care, feel free to find a doctor who will give it to you; if you are going to come to this office I will make you come in on a regular basis.  If you don't think I am worth it, then I am sorry."

He sat quietly for a moment, and I took a deep breath.  "Don't you have a health savings account?" I asked, trying to calm my voice again.  "Most people with high-deductible plans have HSA's."

"Yes, we have an HSA, but we are trying to hold on to that money."

"An HSA is an insurance plan!" I said, not hiding my incredulity.  "This is what you've been saving that money for!  I want to keep you out of the hospital, keep you from the emergency room, and keep you from spending all your money for a hospital stay.  One overnight stay in the hospital will cost you more than 100 visits to my office."

He again sat quietly for a moment, and I directed him up on the exam table.  We talked about his medications and potential side effects.  I pointed out that there are cheaper alternatives for his blood pressure pill that have fewer side effects.  I discussed cardiac screening tests and explained the pros and cons of prostate cancer screening.

I changed his prescription to something cheap enough to recoup the cost of my visit in two months.  As the visit went on, his eye contact grew less and less.  My point was made.  I was giving him something the Internet or a "doc hotline" couldn't give; I saved him money, educated him, and improved his life.

When I had finished with the visit, I handed him the clipboard.  "I'll see you in six months."

He didn't respond, but I could see that he got far more out of the visit than he expected.  I am the one doctor out there whose main goal is to keep him away from the hospital and away from having expensive tests.  I often tell my patients that my goal is to get all of my patients very old and to see them as infrequently as possible.

But I am not a vending machine for prescriptions.  I won't work for free.  I won't take risk without expecting to be paid for it.

I hope he comes back.

I hope he realizes I am worth it.

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